RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-03721
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150710
SEPARATION DATE:  20050530

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Communication/Crypto) medically separated for a mental health condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS).  She was issued a temporary U4S1 profile and referred for a Medical Evaluation Board (MEB).  Depression, with probable somatization disorder; chronic low back pain (LBP); bilateral wrist pain after carpal tunnel release; bilateral knee pain; hypersomnolence disorder without obstructive sleep apnea (OSA); tinnitus; urge incontinence; fibromyalgia; and dysthymic disorder were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated dysthymic disorder as unfitting rated 10%, with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The wrist, knee, and personality disorder conditions were determined to be Category II (can be unfit, but not compensable/ratable).  The PEB made no adjudication of the remaining conditions.  The CI made no appeals, and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any condition outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20050531	VA* - (~5 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Dysthymic Disorder	9433	10%	Dysthymic Disorder	9433	30%	20051024	
Personality Disorder…	Category II					
Depression…	Not Adjudicated					
Hyper-somnolence Disorder…	Not Adjudicated	Narcolepsy	8099-8108	NSC		
Wrist Pain after CTR, Bilateral	Category II	S/P Left Carpal Tunnel Release	8515	0%		
		S/P Right Carpal Tunnel Release	8515	0%		
Knee Pain, Bilateral	Category II	Left Knee Patellofemoral…	5010-5260	10%		
		Right Knee Patellofemoral…	5010-5260	10%		
Chronic Low Back Pain	Not Adjudicated	Lumbosacral Strain…	5010-5237	10%		
Tinnitus	Not Adjudicated	Tinnitus	6260	NSC		
Urge Incontinence	Not Adjudicated	Urge Incontinence	7599-7512	0%		
Fibromyalgia	Not Adjudicated	Fibromyalgia	5025	0%		
Other x 0 (Not in Scope)	Other x 14	
Combined:  10%	Combined:  70%	
*Derived from VA Rating Decision (VARD) dated 20060516 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Dysthymic Disorder.  The Board notes that all mental health conditions are considered under VASRD §4.130 and the depression with probable somatization disorder is considered with the dysthymic disorder.  The record shows that the CI had long standing mental health visits going back to at least 1994 and these were secondary to relationship issues.  The CI had four marriages, the first of which ended prior to enlistment and the second within one year of accession.  Two years prior to separation, the CI was seen in family advocacy for unsubstantiated child neglect.  Following this, the CI was seen in counseling in mental health on a regular basis until separation.  Her diagnoses included a depressive disorder not otherwise specified (NOS), an adjustment disorder with anxiety and depression, a dysthymic disorder, and a personality disorder NOS with Cluster C traits (showing anxious or fearful thinking and behavior).  A health survey on 20 October 2005 noted that the most stressful thing in the CI’s life was her divorce (third) and a custody battle.  The final Enlisted Performance Report in the record, which closed out on 27 October 2004, noted that she met “acceptable levels of performance” but “needs some supervision.”  At the MEB Narrative Summary (NARSUM) Mental Health Examination dated 14 January 2005, approximately 4 months before separation, the CI reported a long standing history of depression and mental health issues.  She reported that work problems developed in the context of frequent medical appointments around the time of her divorce and custody battle.  She continued to endorse dysphoria (abnormal mood), fatigue and poor energy, and multiple musculoskeletal complaints.  She had difficulty balancing her work and parental responsibilities.  She was pending a divorce at the time of her evaluation.  On examination, she was in no acute distress and appropriately dressed and groomed.  She displayed very mild psychomotor retardation and was slumped in her chair.  Her mood was dysphoric and insight fair.  The mental status examination was otherwise unremarkable.  Her condition was thought to have existed prior to service.  Her personality disorder was thought to pre-dispose her to her affective (depression and anxiety) disorder and the risk of recurrence was high.  Her GAF (global assessment of function) was 58, consistent with moderate symptoms or impairment.  She was issued an S4 profile.  Prior to this, the CI had carried an S-1 profile and was worldwide qualified.  Her last mental health encounter on active duty was 4 months later on 17 May 2005, 2 weeks prior to separation.  Her GAF was 70 indicative of some mild symptoms or impairment, but she retained an S4 profile.  Her mood was improved; she planned to move back to Denver with her son and begin school.  She felt optimistic.  The evaluator, a psychiatrist, had seen the CI previously and also co-signed the NARSUM.  At the VA Compensation and Pension (C&P) examination on 24 October 2005, approximately 5 months after separation, the CI reported that she was not currently receiving any psychiatric care.  She was now divorced and living with her son and had custody every other week.  She was taking 5 prep courses for college and planned to study Spanish and finance.  She had a regular schedule and took her son to daycare (when she had custody) as she had at least one class daily.  She was trying to start a business and socialized with a girlfriend 1-2 times a month.  She stated that her mood was dependent on what was going on in her life at that time.  On examination, she was depressed and her affect restricted.  She reported intermittent suicidal ideation, but had no current plan.  She was thought to have a dysthymic disorder and a GAF of 60, at the upper limit of moderate symptoms or impairment.  No personality disorder was diagnosed.  

The Board directed attention to its rating recommendation based on the above evidence.  It first considered VASRD §4.129 (mental disorders due to traumatic stress) and determined that this was not applicable.  It then considered the rating IAW VASRD §4.130 (mental health disorders).  The PEB rated the dysthymic disorder at 10%, coded 9433 (dysthymic disorder).  The VA rated the dysthymic disorder at 30%, also coded 9433, relying on the post-separation C&P examination.  The Board considered the description for the 10% level of impairment “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication” and that for the 30% rating “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal)”.  It noted that there was no evidence that she was unable to perform her job while in service (other than time lost for medical appointments) and that after separation, she had moved to a new city, was in school, a single mother (half-time), and socialized with at least one friend.  At the time of separation, her divorce was final and she was optimistic.  The Board also observed that some of her difficulty was secondary to the underlying personality disorder, which is not a ratable condition IAW DoDI 1332.38.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the dysthymic condition.  

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the wrist pain after carpal tunnel surgery, bilateral knee pain, and personality disorder were not unfitting.  The personality disorder is not ratable as discussed above.  The MEB also forwarded chronic low back pain (LBP), hypersomnolence without obstructive sleep apnea, tinnitus, urge incontinence, and fibromyalgia, to the PEB.  These conditions were not specifically listed by the PEB as unfitting diagnoses implying that the PEB found these not unfitting as well.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The final profile was dated 12 April 2005 and was P1U4L1H1E1S1.  The Board noted that the S1 listed here is not consistent with the S4 recorded at the final mental health visit.  The commander commented that her profile limited her from push-ups and running and that she missed work due to medical appointments.  She was working alternate duties, but these were close to her primary work requirements.  The commander further noted that “Due to the nature of [CI’s] physical ailments and the resulting pain and mental anguish, she does not appear to be able to gain sufficient motivation and desire to overcome her medical problems and continue an active duty service commitment.”  The Board considered each condition separately.

Bilateral Wrist.  The CI had bilateral surgery for carpal tunnel syndrome (CTS) in July 2004.  The NARSUM showed decreased range-of-motion (ROM) from pain, but a normal neurological examination.  Electrodiagnostic testing on 25 February 2005 showed persistent signs of CTS, but improved from prior to surgery.  She was advised to return to orthopedics in a year or if her symptoms worsened, but otherwise released from follow-up.  At the time of the VA C&P examination on 24 October 2005, she reported that she had pain after prolonged driving, writing, or using the computer for over 30 minutes.  However, the VA mental health C&P the same day noted that she “enjoys playing solitaire on the computer for long hours at a time.”  The VA examiner made no comment on the neurological examination and the ROM was noted as normal without increased symptoms on repetition.  

Bilateral Knees.  The NARSUM examiner documented that the CI had slight tenderness to palpation but an otherwise normal examination.  At the VA C&P, the CI reported pain with activity.  On examination, she had a normal gait, was able to get on and off the examination table easily, and a stable knee.  Meniscal signs were absent.  A sign for patello-femoral syndrome was present.  Flexion was reduced to 130 degrees (from normal 140) and painful.  However, the 64 inch CI weighed 200 pounds; no comment was made on possible mechanical limitation from body habitus.  

Low Back Pain.  In the three years prior to separation, there is one annotation for LBP which was noted on a periodic health questionnaire.  The NARSUM documented a normal examination.  The VA examiner noted a normal gait and that she was able to get on and off the examination table easily.  Extension was decreased 10 degrees, but the ROM was otherwise normal.  The paraspinal muscles were tender, but there was no spasm.  

Hypersomnolence without Obstructive Sleep Apnea.  At the VA examination, the CI reported a 5-year history of being “sleepy” all the time.  She had taken an anti-depressant without benefit.  She noted that an evaluation for sleep apnea had been negative.  The record does not show that she was unable to perform her duties from the sleep disorder as an independent condition.  No sleep disorder was diagnosed; from the record, it appears to be a symptom associated with the underlying dysthymic disorder.  

Tinnitus.  Review of the record shows one clinical visit for tinnitus in 2001 in conjunction with an evaluation for ear “stuffiness” associated with allergies.  There is no indication in the record that it ever impaired duty performance.  

Urge Incontinence.  The record shows one appointment in October 2004 in which the CI reports incontinence.  She thought that she might have fibromyalgia.  The VA examiner noted that the CI reported incontinence with stress (coughing, sneezing), but did not record the use of pads.  No duty impairment was documented.  

Fibromyalgia.  The Board found no clinical visits for the fibromyalgia condition other than the evaluation noted for urge incontinence.  She was placed on a medication for the condition Gabatril, which is used “off-label” for fibromyalgia.  The VA C&P examiner noted that she had been diagnosed with this in early 2005 and was treated with an aspirin like medication.  

All the conditions were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at the time of separation.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the dysthymic disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended wrist pain after carpal tunnel surgery, bilateral knee pain, and personality disorder, the Board unanimously recommends no change from the PEB determinations as not unfitting.  In the matter of the contended chronic LBP, hypersomnolence without obstructive sleep apnea, tinnitus, urge incontinence, and fibromyalgia conditions, the Board unanimously agrees that it cannot recommend them for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140722, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03721.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied. 

Sincerely,

XXXXXXXXXXXXXXX 
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings